SABCS 2014: Contralateral Prophylactic Mastectomy

Fiona WilmotBy Fiona Wilmot, MD, MPH, BCAction Program Consultant

This series of talks (session citation below) focused on the clinical implications of the rising trend of Contralateral Prophylactic Mastectomy (CPM). The  data from 1998 – 2010 show a striking decrease in both unilateral mastectomy and breast conserving surgery (from 45%-35% and 50%- 45% respectively in women aged 40-49 years) with a related increase in bilateral mastectomy (from less than 5%- to 25% in same age group). The trends are similar for other age groups – with an even bigger change for women less than 40years – and  a less drastic change for women 50-64 years and greater than 65 years.

It is important to note that these changes are happening in the face of a decreasing incidence of cancer in the contralateral breast (the breast that does not have cancer), and no good evidence suggesting CPM reduces mortality. In short, the significant increase in CPM shows no survival benefit or reduction in cancer of the healthy breast.

Some of the factors that may be driving these marked changes include younger age, anxiety and an overestimation of the risk of developing contralateral breast cancer, a preference for a more symmetrical reconstruction, and wider use of pre-operative breast MRI and genetic testing. It is equally important to note that women report a very high satisfaction with their CPM decision.

When discussing CPM, in addition to the lack of survival benefit, there are the significant risks of the surgery itself to be considered. Any major surgery comes with risks and complications. Not only does mastectomy itself come with the general risks of anesthesia (which are greater for people in poor health), but there’s also risks such as infection, necrosis, and all-too-common seromas. If women choose reconstruction, there are additional risks and complications — consider that 46 percent of women with silicone gel implants and 21 percent with saline implants undergo at least one re-operation within three years.

Many women note that there are quality-of-life related reasons why women opt for CPM above and beyond hoping the surgery will help them survive breast cancer. Some women prefer to have both breasts removed because they desire symmetry, whether they choose reconstruction or not, or have back or neck pain with only one breast.

There is no single right answer for all women, but in order for each of us to make the choice that is best for us in our own circumstances and lives, we must balance fear with facts, and to do so, we need good information. After that, we must trust the fact that every woman is doing her best in difficult circumstances and honor her decisions as her own.

Session: Contralateral Prophylactic Mastectomy: Controversies and Trends

Moderator: Ismail Jatoi, MD, PhD, FACS, UT Health Science Center, San Antonio, TX.

Clinical implications of contralateral prophylactic mastectomy: Ismail Jatoi, MD, PhD, FACS, UT Health Science Center San Antonio, TX.

Contralateral prophylactic mastectomy: Patient preferences and risk perceptions: Ann Partridge, MD, MPH, Dana-Farber Cancer Institute, Boston, MA.

What are the implications for reconstruction following contralateral prophylactic mastectomy? Andrea L. Pusic, MD, MHS, Memorial Sloan-Kettering Cancer Center, New York, NY.

This entry was posted in BCA News.